Nondiagnostic Samples Research Articles

High Diagnostic Yield of Fine Needle Biopsy for Pancreatic Serous Cystadenomas - a Multi-Center Study.

Distinguishing serous cystadenoma, a benign pancreatic cyst, from potentially malignant mucinous pancreatic cystic lesions carries significant clinical and prognostic implications; and while endoscopic ultrasound-guided fine needle aspiration is the standard diagnostic tool, its low diagnostic yield often results in additional workup. This study evaluates diagnostic yield of fine needle biopsy (FNB) on lesions suggestive of serous cystadenoma on endoscopic ultrasound. Patients with microcystic EUS appearance were identified through retrospective chart review in two institutions. Prior cross sectional imaging diagnosis was also obtained. All microcystic lesions with classic "honeycomb" appearance for serous cystadenoma on EUS were targeted for FNB and their pathology evaluated. Patients were identified through database search from 2015 to 2022 and procedure information was obtained through a retrospective chart review from two large academic centers. Thirty-one patients with suspected serous cystadenoma who underwent EUS-FNB were included. EUS FNB was successful in obtaining diagnosis in 96.8% of patients. Serous cystadenoma was diagnosed via EUS FNB in 27 of 31 patients (87.1%). Of the remaining four patients, there was one invasive pancreatic ductal adenocarcinoma, one pancreatic neuroendocrine tumor, one intraductal papillary mucinous neoplasm, and one nondiagnostic sample. EUS-FNB sampling for histopathology is a safe and accurate diagnostic tool for pancreatic serous cystadenoma. When microcytic lesions are found on endoscopic ultrasound, our study results suggest that fine needle biopsy for histopathology should be considered as the initial diagnostic evaluation tool given the demonstrated improved diagnostic yield for serous cystadenoma.

Journey to the Centre of the Ovale: A Novel, Combined Percutaneous Fluoroscopic and Image-Guided Approach to Biopsy a Meckel's Cave Lesion

Abstract Introduction The percutaneous Hartel's technique is a well-described approach to targeting lesions in the Meckel's cave. It is used as the standard approach for all percutaneous trigeminal neuralgia procedures for accessing the Gasserian ganglion through the foramen ovale, be it for a balloon compression, glycerol rhizolysis, or radiofrequency ablation. It has also been described in the literature as an approach to biopsy lesions in the Meckel's cave and cavernous sinus using fluoroscopic guidance; however, there were a significant number of nondiagnostic samples. No one to date has described a combined fluoroscopic and image-guided approach to improve safety and accuracy. Methods The patient had a 3-month history of left-sided facial numbness and a left VIth palsy causing diplopia and a squint. The computed tomography of the chest, abdomen, and pelvis was unremarkable as were the serum tumor markers. We describe the novel approach of using a percutaneous biopsy needle to obtain a cytological sample of a Meckel's cave lesion using a combination of X-ray and electromagnetic image guidance with use of StealthStation S8 System (Medtronic Sofamor Danek, Memphis, Tennessee, United States). The need for a craniotomy and its associated morbidity and technical challenges was therefore obviated. Results The procedure was performed under general anesthesia and eight core samples were sent to neuropathology for analysis. The lesion was histologically confirmed to be lymphoma, and the patient subsequently received oncological treatment. The patient had no immediate or postoperative complications, and the use of the aforementioned combined approach improved safety and accuracy of targeting the lesion in real time. Conclusion A combined percutaneous fluoroscopic and image-guided approach to biopsy a Meckel's cave lesion is recommended, as it improves safety and accuracy.

Sonographic risk stratification of FDG-avid thyroid nodules using the Thyroid Imaging Reporting and Data System.

The increasing usage of positron emission tomography/computed tomography (PET/CT) for detection and monitoring of malignancy has led to an increase in incidental detection of thyroid nodules. Nodules that demonstrate increased avidity for 2-[18F]-fluoro-2-deoxy-d-glucose (FDG) have been shown to carry a high incidence of malignancy and warrant further investigation. At present, there has been limited research on the risk stratification of FDG-avid thyroid incidentalomas. Thus, this study aims to evaluate the efficacy of the ACR TIRADS classification in the risk stratification of such nodules. Data were collected retrospectively for FDG-avid thyroid incidentalomas over a 10-year period. Nodules were characterised using the TIRADS classification and, subsequently, underwent fine-needle aspirate cytology. Cytological findings were classified using the Bethesda reporting system. Non-diagnostic samples (Bethesda class I) were excluded. The remaining samples were divided into two groups: benign (Bethesda class II) or suspicious for malignancy/malignant (Bethesda class III or above). Thirty-six percent of low-risk nodules and 45% of high-risk nodules were malignant, respectively (P = 0.516). The sensitivity and specificity of TIRADS for detection of malignant nodules were 56% and 54%, respectively. There were no malignant TIRADS 1 or 2 nodules. The absence of any suspicious sonographic features had a 1.0 negative predictive value. FDG-avid nodules classified as TIRADS 1 or 2 or have no suspicious ultrasound features have a 0% incidence of malignancy and thus may not require further assessment with fine-needle aspirate cytology (FNA) when detected incidentally. FDG-avid nodules that are TIRADS 3 or above should undergo FNA regardless of size due to the high risk of malignancy and poor sensitivity of the TIRADS classification system.

Ultrasound Imaging of Thyroid Pathologies: A Pictorial Review

AbstractWith its complex embryological origin, the thyroid can be affected by various congenital, developmental, benign, and malignant pathologies. Ultrasound, which is free from radiation and offers good spatial resolution, is the initial modality of choice in congenital hypothyroidism and is used in conjunction with scintigraphy. High-resolution ultrasound also aids in early diagnosis, risk stratification, and follow-up of nodules. While fine-needle aspiration cytology is the preferred method for further evaluation of thyroid nodules, ultrasound guidance reduces the likelihood of obtaining nondiagnostic samples. Numerous risk stratification guidelines for thyroid nodules have been developed by various societies over the past decade, with the most popular being the American College of Radiology—Thyroid Imaging Reporting and Data System. A comprehensive understanding of the varying morphological appearances of thyroid nodules and the consistent use of risk stratification guidelines can accurately detect incidental malignancies while avoiding unnecessary intervention in seemingly benign nodules.

FRI368 Thyroid Paraganglioma: A Rare Manifestation Of Paraganglioma Syndrome Associated With SDHD Mutation

Abstract Disclosure: K. Samuel: None. C. McMullen: None. C. Veloski: None. S. Kushchayev: None. J.E. Hallanger-Johnson: None. J. Hernandez Prera: None. J. Muzaffar: None. G.Q. Yang: None. V. Tarasova: None. Background: Thyroid paragangliomas (TP) are exceptionally rare, representing 0.5% of all paragangliomas (PGL) with total of less than 70 cases reported to date. We report a case of a TP presenting with an indeterminate thyroid nodule, as a first manifestation of multifocal head and neck PGL, associated with succinate dehydrogenase complex subunit D (SDHD) mutation. Clinical case: A 59-year female was initially seen at the tertiary referral center for an indeterminate thyroid nodule discovered incidentally on neck ultrasound (US) ordered for evaluation of a palpable posterior left neck mass. Neck/thyroid US showed multiple nonspecific bilateral lymph nodes measuring up to 1.2 cm and a 1.7 cm right interpolar markedly hypoechoic and hypervascular solid thyroid nodule (TR5). Clinically, the patient did not have symptoms related to the thyroid nodules or lymph nodes in the neck. Thyroid function tests were within normal range. An US-guided FNA biopsy was nondiagnostic. Core biopsy was suspicious for papillary thyroid carcinoma (hypercellular thyroid parenchyma with some follicular cells with nuclear irregularity, grooves, and hyperchromasia). Pathology slides review at the tertiary center showed nondiagnostic sample (Bethesda I) on cytopathology and neuroendocrine neoplasm consistent with PGL on core biopsy (immunohistochemical stains showed tumor cells positive for synaptophysin, chromogranin and GATA3. TTF1, TG, calcitonin, CEA and AE1/3 negative). US of the neck/thyroid 4 months later showed stable disease. Calcitonin and 24-h urinary catecholamines, metanephrines were within normal limits. There was no family history of pheochromocytoma or PGL. Genetic testing showed germline SDHD mutation (p.P81L(c.242c>5). 68Ga-DOTATATE PET/CT revealed multifocal areas of increased somatostatin receptor expression from the skull base to the left thoracic inlet, which included right and left skull base lesions, left neck level IIA lymph node, right and left level III lymph nodes, right thyroid lobe lesion, and left prevascular superior mediastinal lesion. An MRI of the brain and neck with and without contrast showed 1.7 cm right jugular, 0.6 cm right carotid, and 0.6 cm left vagal PGL, 1.3 cm right thyroid nodule, left level II 1.1x.6 cm lymphadenopathy, and 0.4 cm left superior mediastinal nodule. A CT of the neck w/contrast showed multiple areas likely representing bilateral carotid body tumors, left vagal PGL, right glomus jugular, and thyroid PGL stable over 6 months. MIBG nuclear medicine scan revealed no radiotracer accumulation in the lesions. EBRT therapy is planned to the skull base lesion. Conclusions: TP should be considered in the differential diagnosis of hypervascular thyroid nodules in patients with SDH-related pheochromocytoma-PGL syndromes. This case illustrates the importance of experienced multidisciplinary team evaluation and management of complex and rare PRG cases. Presentation: Friday, June 16, 2023

Transbronchial Cryobiopsy Is Superior to Forceps Biopsy for Diagnosing both Fibrotic and Non-Fibrotic Interstitial Lung Diseases

Background: Interstitial lung disease (ILD) evaluation often requires lung biopsy for definite diagnosis. In recent years, transbronchial cryobiopsy (TBCB) emerged as a procedure with higher diagnostic yield than transbronchial forceps biopsy (TBFB), especially for fibrotic ILDs. Nonetheless, studies comparing these modalities in non-fibrotic ILDs and for specific ILD diagnoses are scarce. Objectives: The aim of this study was to evaluate the diagnostic yield and safety of TBCB and TBFB in patients with fibrotic and non-fibrotic ILDs. Method: An observational retrospective multicenter study including patients with ILD diagnosis by multidisciplinary discussion that underwent TBCB or TBFB between 2017 and 2021. Chest CT scans were reviewed by a chest radiologist. Biopsy specimens were categorized as diagnostic (with specific histological pattern), nondiagnostic, or without lung parenchyma. Nondiagnostic samples were reassessed by a second lung pathologist. TBCB and TBFB diagnostic yields were analyzed by multivariate regression. Procedural complications were evaluated as well. Results: 276 patients were included, 116 (42%) underwent TBCB and 160 (58%) TBFB. Fibrotic ILDs were present in 148 patients (54%). TBCB diagnostic yield was 78% and TBFB 48% (adjusted odds ratio [AOR] 4.2, 95% CI: 2.4–7.6, p < 0.01). The diagnostic yield of TBCB was higher than TBFB among patients with fibrotic ILD (AOR 3.8, p < 0.01), non-fibrotic ILD (AOR 5.8, p < 0.01), and across most ILD diagnoses. TBCB was associated with higher risk for significant bleeding (10% vs. 3%, p < 0.01), but similar risk for pneumothorax. Conclusions: Diagnostic yield of TBCB was superior to that of TBFB for both fibrotic and non-fibrotic ILDs, and across most diagnoses.

Reducing non diagnostic thyroid cytology using on-site adequacy assessment performed by junior medical staff

Objective:To assess efficacy of bedside cytology assessment of thyroid fine needle aspirate samples performed by junior medical staff compared to cytologists. Methods: Retrospective analysis was performed of 1490 thyroid fine needle aspirates. Samples were divided into three groups: cellular adequacy assessment performed by cytologists, interns, and no onsite adequacy assessment (blind). A 45-minute training session was provided to medical interns with the aim of identifying whether adequate cellular material was demonstrated, as defined by the Bethesda criteria. The primary outcome was the rate of nondiagnostic samples, and the secondary outcome was the number of fine needle aspirate passes required to reach sample adequacy. Results: The incidence of non-diagnostic samples for the cytologist, blind, and intern groups were 6.90%, 17.1% and 14.0% respectively (p&lt;0.001). There was no statistically significant difference in non-diagnostic rate between the blind and intern groups. Significantly more aspirates required more than two passes in the cytologist group (74.8%) and blind (94.7%) compared to the intern group (58.7%, p&lt;0.001). Conclusions: On-site adequacy assessment performed by cytopathologists is the gold standard for minimising non-diagnostic thyroid FNAs, however, medical staff with minimal anatomical pathology experience can be trained to perform on-site adequacy assessment and improve outcomes with the implementation of a simple targeted training program.

Approach to Cohort-Wide Re-Analysis of Exome Data in 1000 Individuals with Neurodevelopmental Disorders.

The re-analysis of nondiagnostic exome sequencing (ES) has the potential to increase diagnostic yields in individuals with rare diseases, but its implementation in the daily routines of laboratories is limited due to restricted capacities. Here, we describe a systematic approach to re-analyse the ES data of a cohort consisting of 1040 diagnostic and nondiagnostic samples. We applied a strict filter cascade to reveal the most promising single-nucleotide variants (SNVs) of the whole cohort, which led to an average of 0.77 variants per individual that had to be manually evaluated. This variant set revealed seven novel diagnoses (0.8% of all nondiagnostic cases) and two secondary findings. Thirteen additional variants were identified by a scientific approach prior to this re-analysis and were also present in this variant set. This resulted in a total increase in the diagnostic yield of 2.3%. The filter cascade was optimised during the course of the study and finally resulted in sensitivity of 85%. After applying the filter cascade, our re-analysis took 20 h and enabled a workflow that can be used repeatedly. This work is intended to provide a practical recommendation for other laboratories wishing to introduce a resource-efficient re-analysis strategy into their clinical routine.

Multiparametric MRI to quantify disease and treatment response in mice with myeloproliferative neoplasms.

Histopathology, the standard method to assess BM in hematologic malignancies such as myeloproliferative neoplasms (MPNs), suffers from notable limitations in both research and clinical settings. BM biopsies in patients fail to detect disease heterogeneity, may yield a nondiagnostic sample, and cannot be repeated frequently in clinical oncology. Endpoint histopathology precludes monitoring disease progression and response to therapy in the same mouse over time, missing likely variations among mice. To overcome these shortcomings, we used MRI to measure changes in cellularity, macromolecular constituents, and fat versus hematopoietic cells in BM using diffusion-weighted imaging (DWI), magnetization transfer, and chemical shift-encoded fat imaging. Combining metrics from these imaging parameters revealed dynamic alterations in BM following myeloablative radiation and transplantation. In a mouse MPLW515L BM transplant model of MPN, MRI detected effects of a JAK2 inhibitor, ruxolitinib, within 5 days of initiating treatment and identified differing kinetics of treatment responses in subregions of the tibia. Histopathology validated the MRI results for BM composition and heterogeneity. Anatomic MRI scans also showed reductions in spleen volume during treatment. These findings establish an innovative, clinically translatable MRI approach to quantify spatial and temporal changes in BM in MPN.

P11.07.B What is the role of brain biopsy in the diagnosis of brain lesions?

Abstract Background Brain biopsies have a role in establishing histological diagnoses for intrinsic tumours not amenable to surgical resection or lesions with an uncertain radiological diagnosis. Despite their utility, they are associated with several risks, particularly surgical complications and non-diagnostic samples. On this background, this study sought to determine the diagnostic yield and outcomes of brain biopsies carried out in a tertiary centre and explore factors which could influence the overall success of such procedures. Material and Methods All non-endoscopic brain biopsy procedures performed over a 1-year period (01/04/2020 to 01/04/2021) at one of the largest neurosurgical units in the UK were included. Hospital electronic records were used to identify eligible patients and determine relevant patient, procedure and outcome data. Mortality data were obtained with a minimum follow-up period of 1 year. Results A total of 75 cases were identified, including 55 burr hole biopsies and 20 open procedures. Overall, 16 (21%) biopsies were non-diagnostic, including 25% of burr hole biopsies and 10% of open biopsies. Procedures performed by a consultant had a lower non-diagnostic rate (17%) than cases with no consultant involvement (27%). Suspected inflammatory conditions had a higher non-diagnostic rate (55%) than suspected tumours (11%). Excluding non-diagnostic cases, histological diagnosis was in line with suspected pre-operative diagnosis in 70% of cases. Post-operative complications included 3 symptomatic haematomas and 1 subdural empyema, which led to one post-operative death. A total of 40 (55%) patients died within the follow-up period, including 10 (13%) within 60 days of their procedure. Six-month and 1 year survival rates were 35% and 26% for glioblastoma, respectively, and 70% and 70% for lymphoma. The majority (68%) of patients with a performance status (PS) of 3 or 4 prior to surgery died within 1 year, as compared to 42% with a PS of 0-2. Conclusion Brain biopsies are an important adjunct to managing CNS lesions due to the limitations of a radiological diagnosis alone. The diagnostic yield was greater for suspected neoplastic lesions, in cases with consultant involvement, and with open procedures.

Transbronchial Cryobiopsy vs Conventional Forceps Biopsy in Lung Transplant Recipients Multicenter Study

<h3>Purpose</h3> Transbronchial biopsy is considered the gold standard in the diagnosis of acute cellular rejection after lung transplantation. There still remains the discussion in conventional forceps biopsy comparing to cryobiopsy in lung transplant recipients. This study aims to compare the diagnostic yield and potential complications in both procedures. <h3>Methods</h3> In retrospective multicenter study all transbronchial biopsies (TBBs) were evaluated since 2010 till 2019. Surveillance TBBs were performed in 1, 3, 6 and 12 months after lung transplantation. Additional diagnostic bronchoscopies were performed if clinically indicated. Pneumothorax was categorized as none, partial recovered without treatment and pneumothorax required inserting of chest drainage. Bleeding was predefined as none, mild bleeding requiring suction and instillation of cold saline solution and severe bleeding requiring additional instillation of adrenaline. TBBs were graded according to the International Society of Heart and Lung Transplantation (ISHLT) consensus guidelines for the diagnosis of lung allograft rejection. <h3>Results</h3> In 309 patients a total of 448 forceps biopsies and 573 cryobiopsies were performed. The incidence of pneumothorax was significantly (p<0,001) higher after forceps biopsies (9,2 % vs 3,3 %). Bleeding was significantly greater in the cryobiopsy group (cryobiopsy/forceps biopsy: no bleeding 80,4%/96,4%; mild 15,4%/2,4%; severe 4,2%/1.1%; p < 0.001). The mean size of cryo-specimen was five times larger than forceps-group samples. The diagnostic rate of acute rejection using cryobiopsy and forceps biopsy was similar A0 grade 36% vs 39%, A1 grade 46% vs 35%, A2 grade 14% vs 17,5%, A3-A4 grade 4% vs 8,5%. But evidently larger specimens from cryobiopsy catched the presence of bronchiolus in 51% compared with 8% from forceps samples which shows the major significance (p<0,001). <h3>Conclusion</h3> Transbronchial cryobiopsies compared to traditional forceps biopsies provided superior quality of the specimens with significantly higher capture of bronchiolus and lower rate of non-diagnostic samples which also enable potential possibility for futher evaluation of humoral and chronic rejection. Cryobiopsies reduce the number of specimens with acceptable complications.

Diagnostic value of liquid-based cytology test in intrathoracic lymph nodes and lung lesions sampled by endobronchial ultrasonography-transbronchial needle aspiration.

Liquid-based cytology (LBC) has begun to be used in non-gynecological samples such as endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). This study aims to investigate the diagnostic value of LBC in intrathoracic lymph nodes and lung lesions sampled with EBUS-TBNA. In total, 174 cases that underwent EBUS-TBNA between July 2020 and February 2021 were included (75 and 99 cases were prepared using conventional and LBC methods, respectively). The two groups were compared in terms of diagnostic categories, number of slides, cell blocks, slides per location, locations sampled, immunohistochemical studies, sensitivity, specificity, and diagnostic accuracy. The percentages of malignant, suspicious for malignancy, benign, and non-diagnostic (ND) cases were 51.8%, 1.1%, 39.6%, and 7.5%, respectively. The LBC and conventional group (CG) had similar rates in the diagnostic categories, except for ND (3.0% and 13.3%, respectively). The sensitivity of LBC and CG were 90.4% and 85.7%, respectively. There were no differences in the specificity and diagnostic accuracy between groups. There was a statistically significant difference between groups in terms of the number of slides, number of slides per location, number of cell blocks, and locations sampled (p < .001, p < .001, p < .05, p < .05). The LBC technique can be used for samples taken with EBUS-TBNA. Rapid fixation and the absence of artificial problems greatly reduce the rate of ND samples in LBC slides. Other important advantages are a lower number of slides to examine and a greater number of cell blocks.

BRAIN Surgical Tissue for Advanced Tumour models in Precision medicine: Developing the BRAIN-STAT pathway

AimsThere are approximately four thousand neuro-oncology procedures in the UK per annum. Many of these result in tissue and biofluid specimens that are surplus to diagnostic requirement and can be collected as standard of clinical care. However, developing technologies and treatments for precision medicine require access to a range of individualised biospecimens paired with deep clinical phenotyping data. Here, we present Brain Surgical Tissue for Advanced Tumour Models (BRAINSTAT) programme, an infrastructure that has been established between Queen Elizabeth Hospital, Birmingham and the University of Birmingham, to collect, structure and store these resources and also maximise their value for research over the long-term. Using this approach our aim is to provide high-quality, annotated resources to help develop novel treatments for patients with brain tumours.MethodBRAINSTAT infrastructure allows:Prospective consentBiospecimens, including tumour tissue (brain and other primary in the case of metastasis), cyst fluid, dura, skin, CSF, blood (matched “germ-line” and for circulating cell free tumour DNA analysis), urine and saliva can be collected. Consent for long term follow-up, is either via clinic or NHS digital. More limited consent for non-oncological neurosurgical cohorts (e.g. epilepsy or vascular) and healthy volunteers allow healthy access-tissue and biofluids to be collected.B. Rapid transfer of fresh surgical tissue samples:Strong collaborative links and close physical proximity between operating theatre and laboratory allows rapid transfer of biospecimens minimising transit time.C. Standardised annotation across disciplinesThe RedCAP database system allows granular control over data-access, and each specialist research team is provided access only to the sub-sections relevant to them. All users must have Good Clinical Practice certification and GDPR training, prior to access of the BRAINSTAT database.ResultsBetween 25/11/2019-16/03/2020 and 27/07/2020-16/11/2020, 65 patients were consented for BRAINSTAT at the weekly neurosurgical oncology clinic. (Recruitment gaps due to the SARS-COVID 19 pandemic). Pathological diagnosis of surplus tissue collected included: 37 high grade glioma, 3 low grade glioma and 16 brain metastasis including: (6 lung, 6 breast, 2 colorectal, 1 oesophageal, 1 endometrial). Meningioma (5 WHO I; 1 WHO III) 1 patient undergoing anterior temporal lobectomy for hippocampal sclerosis contributed access tissue from the lateral neocortex. 1 patient had a non- neoplastic, non-diagnostic sample. All patients had matched “germ-line” blood samples.Median time from resection to arrival in the laboratory was 10 minutes (range 4-31). Standardised operating protocols to optimise this have been developed.Glioblastoma and breast-brain metastasis tumourspheres and cerebral organoids are currently being validated.ConclusionDespite the challenges of the pandemic we have established a viable tissue pipeline from neurosurgical operating theatre to our university laboratories. We are developing clinically annotated human brain tumour cell lines, stem cells and 3D organoid models, principally for commonly encountered brain tumours such as glioma and metastasis.The research sets the foundation for a multitude of downstream applications including:- Building more complex organoid cultures e.g. by including other cell types such as healthy brain cells and endothelial cells allowing future experiments to more accurately model tumour growth.- Developing high-throughput, patient-specific drug screens of novel drugs and drug combinations using these 3D tumour models aiming to more effectively treat tumour proliferation and spread. These patient avatars will help inform and test more “stratified” personal medical treatments and will provide opportunities to allow earlier intervention with the aim of improving survival, coupled with a better quality of life.

Single Center Experience with Isolated Spinal Cord Neurosarcoidosis

Isolated spinal cord neurosarcoidosis is extremely rare. The potential implications of long-term immunosuppressant therapy make correct diagnosis imperative. However, there are challenges inherent in isolated spinal cord involvement that require a multidisciplinary approach. Here we present the largest series of definite and possible isolated spinal neurosarcoidosis and discuss our institutional experience in managing this rare but morbid condition. A retrospective review was performed to identify all neurosarcoidosis cases starting from 2002 to 2020 at our institution. Patients were screened for cases of isolated spinal neurosarcoidosis. A descriptive analysis was performed for each case. A total of 64 cases of neurosarcoidosis were identified. The spine was involved in 26 (40.6%) patients. Only 4 (6.3%) cases had isolated spinal cord involvement. A full medical and imaging workup was performed in determining isolated spinal cord involvement. Three patients subsequently underwent surgical biopsy, and 1 did not undergo biopsy because of patient preference. One of the patients who underwent biopsy had an initial nondiagnostic biopsy and had a repeat biopsy. Corticosteroids were employed in all cases with additional immunosuppressive agents for maintenance therapy and refractory cases. All showed radiographic improvement and were clinically stable to improved. Isolated spinal cord involvement of neurosarcoidosis is rare and can present challenges in diagnosis. A biopsy can be performed when necessary. However, a biopsy of the spinal cord carries inherent risks and may not always be possible or result in a nondiagnostic sample. In the setting of high clinical suspicion, maximal medical therapy is still employed.

Focused Neck Ultrasound and Lymph Node Sampling by Respiratory Physicians in Suspected Lung Cancer

Background: Malignant cervical lymphadenopathy in the setting of lung cancer represents N3 disease, and neck ultrasound (NUS) with sampling is described in the Royal College of Radiologists ultrasound training curriculum for the non-radiologists. This study reviews the incorporation of NUS +/− biopsy in the routine practice of a lung cancer fast-track clinic in the UK. Methods: We retrospectively assessed 29 months of activity of a lung cancer fast-track clinic. Systematic focused NUS was conducted in suspected thoracic malignancy, sampling nodes with a ≥5-mm short axis, under real-time US using a linear probe (5–12 Mhz). Fine-needle aspirations (FNAs) with or without 18 Ga core biopsies were taken. Results: Between August 2017 and December 2019, of 152 peripheral lymph nodes (LNs)/deposits sampled, 98 (64.5%) were supraclavicular fossa LNs with median [IQR] size 12 [8–18] mm. Core biopsies were performed in 54/98 (55%) patients, while all patients had FNAs. No complications occurred. The representative yield was 90/95 (94.7%) in cases with suspected cancer. No difference was seen between FNA versus core biopsy (p = 0.44). Of the 5 non-diagnostic samples, one was FNA only. The commonest diagnosis was lung cancer in 66/98 (67.3%). PDL-1 was sufficient in 35/36 tested (97.2%). ALK-FISH was successful in 24/25 (96%) cases. EGFR mutation analysis was successful in 28/31 (90.3%) cases. Median time from clinic to initial diagnosis was 7 [5–10] days. Computed tomography (CT) scans reported no significant lymphadenopathy in 18/96 (18.7%) cases, yet 10/18 (55.5%) cases were positive for malignancy. Conclusion: Neck nodal sampling by respiratory physicians was safe, timely, with a high diagnostic yield and suitability for molecular testing. Neck US can provide a timely diagnosis in cases that may be missed by CT alone.

Safety and Effectiveness of Transthoracic Core Needle Biopsy in a Newly Established Interventional Radiology Program in Tanzania

Abstract Background Transthoracic core needle biopsy (TTCNB) became a routinely offered procedure in Tanzania in October 2018. This study evaluates the safety and effectiveness of establishing a TTCNB program in a resource-limited setting. Methodology A single center, prospective, observational cohort study was conducted at Muhimbili National Hospital on 90 patients who underwent computed tomography-guided TTCNB from October 2018 to May 2021. Patient and procedural data, including demographic information, complications, pathology results, and clinical outcomes, were stored in a Research Electronic Data Capture (REDCap) database. Follow-up was conducted at 4 weeks postprocedure by phone. Descriptive analysis was performed using Statistical Package for Social Sciences. Results A total of 90 patients underwent TTCNB. Seven samples were lost or never processed. In total, 68/83 (81.9%) of processed samples were diagnostic, with 89.7% (n = 61) classified as malignant and 10.3% (n = 7) classified as benign. Overall, 82.4% (n = 56) were classified as primary malignancies, 7.4% (n = 5) as metastatic malignancies, 5.9% (n = 4) as benign tumors, and 4.4% (n = 3) as infectious. Reasons for nondiagnostic samples were crashed/insufficient samples in 53.3% (n = 8) and nonspecific chronic inflammation in 46.7% (n = 7). Minor (Society of Interventional Radiology [SIR] class A and B) complications occurred in 8 cases (8.9%), while there was 1 (1.1%) major complication (SIR class F). A total of 44/90 (48.9%) patients could be reached for follow-up at 4 weeks postprocedure. In addition, 31/44 (70.5%) of these patients had a diagnosis of malignancy. Of these, 20 received chemotherapy, 8 died prior to receiving any treatment, 2 declined any further medical or surgical intervention, and 1 was treated with surgical excision and adjuvant chemotherapy. Conclusion Although recently introduced in Tanzania, TTCNB has been performed with 81.9% diagnostic accuracy and a complication rate comparable to existing literature.

It’s What’s Inside that Counts: Developing a paste group typology in Belize

The ceramic assemblage at the Classic Period Maya site of Alabama, Belize is poorly preserved and fragmentary. Most of the pottery cannot be classified using standard type-variety approaches, which privilege decoration and surface treatment. The nature of the Alabama ceramic assemblage requires a classification system organized by paste wares, as opposed to incorporating paste composition as a modal or analytical unit that crosscuts types and wares, as this is the only attribute that can be reliably evaluated across all contexts. We identified and systematically described paste groups as a first step toward a typology organized by ceramic paste wares. We analysed 100% of ceramics from settlement surface collection at the site, including non-diagnostic samples, using a scaffolded approach that integrates macroscopic observations, Dino-Lite USB microscopy, and thin section petrography. This approach facilitates the analysis of pottery from all contexts, regardless of the degree of preservation. Incorporating paste composition into classification schemes provides important data on pottery production traditions and the people responsible for their production, which cannot be determined from stylistic analyses alone. We established five new paste groups indicative of local and non-local pottery production. Our approach to ceramic classification provides a method that can be applied to any archaeological site, regardless of the prevailing classification system in place, and is especially relevant to sites with poorly preserved ceramic assemblages dominated by non-diagnostic sherds.

Prevalence of pathological lesions diagnosed by cytology in cats, with association of diagnosis to age, breed and gender

Cytology is the diagnostic procedure of the microscopic evaluation of cells. It is becoming increasingly important and more frequently used in veterinary diagnostics, having many advantages including simplicity, speed and low cost. To determine the pathological changes diagnosed by cytology in cats, as well as the distribution of age, breed and gender in the diagnosed changes, we performed a retrospective study on slides submitted to the Department of Veterinary Pathology for routine cytological examination. The archive was searched for all feline cytology slides submitted from 2009 to 2018. All the slides were re-evaluated and classified into one of the four pathological processes: ‘neoplasia’, ‘inflammation’, ‘other condition’ or ‘non-diagnostic sample’. Breed, age, gender and the tissue from which the lesion was sampled were noted from the submission form, and statistically analyzed. The most frequent type of pathological process diagnosed was neoplasia, which reflects the high prevalence of neoplastic diseases in cats reported in literature data. Pathological changes were mostly diagnosed in domestic shorthaired cats of both sexes, with an average age of 8.4 years, but no breed, age or gender predisposition was found. The most evaluated tissue was skin, probably due to its accessibility and the ease of obtaining a sample from skin lesions. The most frequent neoplasia were malignant and the most frequent diagnosis was round cell neoplasia. Cats affected with round cell neoplasia had a significantly lower average age (7.3 years) than cats diagnosed with epithelial and mesenchymal neoplasia (9.9 and 10.3 years, respectively), probably reflecting the common retroviral infection in Croatian cats.

Miniforceps EBUS-Guided Lymph Node Biopsy: Impact on Diagnostic Yield

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the standard diagnostic method for sampling mediastinal and hilar lymph nodes. Non-diagnostic samples have led some pulmonologists to add a miniforceps biopsy (EBUS-TBFB) in order to increase diagnostic yield. Our study aims to analyze the impact of adding EBUS-TBFB to the EBUS-TBNA in cases where Rapid On-site Evaluation (ROSE) was negative for malignancy or was non-diagnostic. This retrospective chart review included 91 patients who were aged 18-90 years old and underwent EBUS with both TBNA and TBFB between January 1, 2013 and July 1, 2018. There was no significant statistical difference in the diagnostic yield of TBNA vs TBFB with a McNemar value of 0.167, and this conclusion was the same when stratified by race, age and lymph node size. Using TBNA as a gold standard, the sensitivity and specificity of TBFB was 87% and 69%, respectively. Out of the non-diagnostic TBNA samples on ROSE and cell-block, subsequent TBFB resulted in additional pathologic diagnoses in 16% of cases, of which 67% were non-caseating granulomas. Furthermore, two additional malignant cases were identified by TBFB consisting of small cell carcinoma and non-Hodgkin's lymphoma. In conclusion, TBFB is a useful adjunctive tool in the diagnosis of non-malignant conditions (i.e. granulomatous diseases) with the potential to spare the patient from more invasive surgical biopsies. Training of future fellows in performing TBFB in addition to TBNA should be strongly encouraged.

Factors affecting thyroid nodule fine needle aspiration non\u2010diagnostic rates: a retrospective association study of 1975 thyroid biopsies

BackgroundThyroid nodules are common in clinical practice, and it is important to distinguish benign nodules, the vast majority, from malignant ones. Non-diagnostic (ND) samples have the potential to delay or mis-diagnose or lead to unnecessary surgeries, and it is important to examine what factors influence the ND rate. Prior literature has suggested that the impact of bedside cytology on ND rate is dependent on the initial adequacy rate, whereby higher ND rates benefit most from bedside cytology. We aim to compare the impact of bedside adequacy review between specialist groups who perform high volume thyroid biopsies with low initial ND rates.MethodsWe reviewed the cytopathology results of 1975 thyroid nodule FNAs performed between January 1, 2017 to December 31, 2017 in a multi-centre Canadian city, and the corresponding histopathology reports of 340 resected nodules. Descriptive variables were used to describe the data along with chi-squared testing and univariate logistic regression.ResultsThe FNA biopsies were performed by three different speciality groups, which differed by procedural volume: radiology performed the most at 1171, pathology performed 655 and surgery performed 103. We could not define the operator for 45 of the nodules. The ND rate was lowest in the speciality groups with highest procedural volume, 3.4 % in pathology and 8.3 % in radiology, compared to 37.9 % in surgery (p < 0.001). Completion of bedside cytology rapid onsite evaluation (ROSE) significantly reduced the ND rate from 16.7 to 4.2 % for all samples (p < 0.001). When ROSE was compared with non-ROSE within a high procedural group (radiology), it further reduced the ND rate from 12.5 to 5.1 % (p < 0.001). Of the 340 resected nodules, 10.7 % (18) were in the ND category, of which 28 % (5/18) of these were found to be malignant (4 papillary carcinoma and 1 lymphoma).ConclusionsThe results from this study demonstrate that thyroid FNAs performed with bedside ROSE can significantly reduce the ND rate compared with non-ROSE, even in experienced groups with low initial ND rates. It is therefore imperative that care providers managing patients with thyroid nodules ensure that thyroid FNAs are referred to specialized individuals/groups who do high volume, and ideally with the use of bedside ROSE, whether provided by a cytotechnologist or a pathologist.